Chapter 05 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 05 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCSA

An older adult patient was hospitalized for 2 weeks before having abdominal surgery 3 days ago. The nurse notes the patient’s hair is broken and dull. Which intervention is indicated?

1. Increase vigilance for dehiscence.
2. Talk to the family about trimming the patient’s hair.
3. Use a protein-based shampoo.
4. Increase the patient’s oral fluid intake.

Correct Answer: 1

Rationale 1: Broken and dull hair may indicate protein-calorie malnutrition. If this condition exists it increases risk for dehiscence of the patient’s abdominal incision.

Rationale 2: Trimming the hair will not reverse the process that is likely occurring.

Rationale 3: External application of protein will not correct the probable source of this change in the patient’s hair.

Rationale 4: Increasing fluid will not change this situation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-1

Question 2

Type: MCSA

A patient with a BMI of 32 is in the intensive care unit recovering from surgery to repair an abdominal aortic aneurysm. What should be the nurse’s focus regarding this patient’s nutritional needs?

1. Support elevated nutrient needs.
2. Maintain on intravenous fluids and clear liquids.
3. Limit food and fluid intake to three mealtimes daily.
4. Begin a weight-reduction program immediately.

Correct Answer: 1

Rationale 1: During acute illness it is crucial to meet the elevated nutrient needs of obese patients to optimize outcomes.

Rationale 2: Weight loss is not the focus of the patient’s current needs.

Rationale 3: There is no reason to limit food to three daily meals. Fluids should not be restricted unless there is a comorbid condition that requires decrease in fluid intake.

Rationale 4: Weight loss is not the focus of the postoperative period.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5-1

Question 3

Type: MCSA

A patient admitted for a gunshot wound to the leg and multiple abdominal stab wounds is transferred to the intensive care unit after surgery. The nurse would evaluate which finding as expected but as requiring monitoring?

1. Blood pressure 170/104 mm Hg
2. Elevated blood glucose level
3. Serum potassium of 5.4 mEq/L
4. Increase in body temperature

Correct Answer: 2

Rationale 1: This blood pressure reading would not be expected with this patient’s mechanism of injury.

Rationale 2: The first 24 hours after a body injury, the body responds with an increase in mobilization of carbohydrates and lipids. Glucose production increases in efforts to support wound healing. The body also responds by decreasing the amount of insulin produced. Because of these bodily responses, the nurse will most likely observe an elevated blood glucose level that will impact the patient’s nutritional needs at this time. This finding is physiologically normal but will require monitoring as the patient heals.

Rationale 3: This potassium level is elevated and is not an expected finding.

Rationale 4: The first 24 hours after a body injury, the body responds with a drop in body temperature. Increased temperature is not an expected finding.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-1